Session Note Template:
For meetings with stakeholders in relation to a client / patient, this template is designed to create formal minutes for use in clinical records.
Please note: For clinical supervision sessions, it is recommended that other templates be used, such as “Clinical Supervision” (between a supervisor and supervisee) or “Peer Supervision” (between two or more colleagues).
Template Structure
Example Output
Template Structure
Clinical Case Review / Meeting Summary
- Time & Date
- Name of the key person / client being discussed in the meeting.
- Location
- Date of next meeting
- Time of next meeting
- Location of next meeting
Example Output
Clinical Case Review / Meeting Summary
- Time & date: 14 May 2025, 10:30-11:45am
- Client / patient: Ryan Jones (DOB: 23/08/2009)
- Location: Northern Community Mental Health Centre, Conference Room 3
- Dr. Nina Patel, Child Psychiatrist, Northern Health, nina.patel@northernhealth.org.au – Medication management and psychiatric assessment
- Jasmine Hughes, Clinical Psychologist, Brightmind Psychology, jhughes@brightmind.com.au – Individual therapy provider since February 2025
- Michael Roberts, School Counsellor, Wattle Park Secondary College, m.roberts@wpsc.edu.au – School-based support and monitoring
- Sophie Chen, Parent/Carer – Mother and primary caregiver
- David Thompson, Case Manager, Youth Support Services, d.thompson@yss.org.au – Coordination of care and resources
- Dr. James Miller, GP, Miller Family Practice – Unable to attend due to emergency at clinic
- Karen Lee, Occupational Therapist – On annual leave
- Review Ryan’s progress since commencing fluoxetine four weeks ago
- Discuss recent school attendance issues and academic performance
- Update on home environment and family dynamics
- Coordination of therapy approaches between providers
- Review and adjust treatment goals
- Ryan has shown mild improvement in depressive symptoms since starting fluoxetine 10mg daily four weeks ago, with mother reporting improved morning routine and slightly increased engagement in family activities.
- Sleep continues to be disrupted with difficulty falling asleep and early morning waking (4-5am) approximately 3-4 times weekly.
- School attendance has dropped to 60% over the past month, with Ryan reporting increased social anxiety, particularly in PE classes and lunch periods.
- Recent academic assessment shows Ryan is performing below expected levels in most subjects despite previous strong academic history.
- Michael Roberts noted Ryan has begun attending the school’s quiet space during lunch breaks and has connected with one supportive peer.
- Mother reports significant family stress due to recent redundancy and financial pressure, which may be contributing to Ryan’s anxiety.
- Jasmine Hughes highlighted Ryan’s increasing use of cognitive strategies in therapy, though catastrophic thinking remains persistent regarding academic performance.
- Ryan has expressed thoughts about “not seeing a future” to both his psychologist and mother, though denies specific suicidal ideation or plans.
- There were differing perspectives on prioritisation of interventions – school counsellor emphasised attendance strategies while psychiatrist suggested focusing on mood stabilization first.
- Dr. Patel to increase fluoxetine to 15mg daily with review in 3 weeks (Sophie to monitor and report any side effects).
- Michael Roberts to arrange reduced timetable focusing on Ryan’s strength subjects for the next 4 weeks, with gradual reintegration plan.
- Jasmine Hughes to focus on specific social anxiety management techniques in next three sessions.
- David Thompson to investigate financial support options for family and provide information by 21 May.
- Sophie Chen to implement consistent bedtime routine using resources provided by Jasmine.
- All providers to use shared communication platform for updates between meetings.
- Ryan to be invited to attend first 15 minutes of next case review meeting.
- Team observed that Ryan’s anxiety appears more pronounced than his depressive symptoms at present, different from initial presentation in January.
- Sophie expressed concern about school’s upcoming camp and team agreed this should be optional for Ryan with appropriate supports if he chooses to attend.
- Michael noted potential bullying situation that requires further investigation – will follow up with year coordinator.
- Date: 11 June 2025
- Time: 10:30am-12:00pm
- Location: Northern Community Mental Health Centre, Conference Room 3
- Template Type
- Session Note
- Note Dictation
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